Thursday, May 29, 2008

A is for Airway

A = Airway
B = Breathing
C = Circulation

The ABCs of CPR are embedded deep within the memories of every health professional. In five months of providing sedation in the endo room, I had never had to actively manage a patient's airway. If an airway was questionable, a simple repositioning of the patient's head would do the trick.

That all changed today. My patient had been snowed by our most heavy-handed doc. Her respiratory rate was fine, but her SaO2 (oxygen saturation) kept dipping, and she was doing this snoring that made me think she was partially obstructing. Plenty of chest movement with each breath, audible breaths, but I just had the feeling she wasn't moving a whole lot of air. A chin lift didn't help much. I turned the O2 up to 3 liters, then 4. Still she was hovering around 88-91% -- certainly no emergency, but I was not comfortable with her being so low. I did a jaw thrust: 92.....93......95......96. I let go: 95.....94.....91.....89.....86. I ended up keeping my hands on her jaw for most of the procedure. It worked great! Luckily, her other vital signs were stable despite the huge amounts of Demerol and Versed in her system. She needed some Narcan and a trip to the PACU because she wouldn't wake up when we were through. I have the feeling that we crossed the line past moderate sedation into deep sedation this time. I wish certain doctors would go to the sedation workshop that I just attended!

Monday, May 26, 2008

I love my Palm TX

My Palm TX travels with me every day in the pocket of my scrubs. I bought it a couple of years ago, and it has proven to be a highly useful and entertaining little gadget. Here are the medical apps I tend to use the most:

Davis's Drug Guide for Nurses:
This is the best PDA drug guide I have found. A lot of the others are designed for physicians and do not have info nurses need to know, such as IV compatibility. I can't tell you how many times this has saved me from running back down the hall to the nurse's station to find a drug book because I couldn't remember whether cipro was compatible with morphine.

Taber's Cyclopedic Medical Dictionary:
Is there a nurse out there who does not own or use Taber's? I have found Taber's to be most valuable when I have a patient with a medical condition I am not too familiar with, but it has been helpful for looking up all sorts of things.

These are the only references I have purchased. At $50 each, they are not cheap, but I have found them well worth the money. I got them through Skyscape; there are other vendors that sell the same references. There are many free medical references available also.

I bought the TX to use at work, but I must admit that I have used it for entertainment more than I have as a medical reference tool. Hundreds of games, many free, are available for the Palm platform. It is an mp3 player and video player; one person I know has the entire Lord of the Rings trilogy on his TX. It has wi-fi and can be used to surf the web at any wi-fi hotspot. And of course, it handles all the PIM (Personal Information Management) stuff beautifully.

It is not a phone; if you want a PDA/phone combo, consider the Palm Treo or smaller Palm Centro. Personally, I prefer keeping my gadgets separate; I'm perfectly happy with my little dumb phone. And the TX has a much larger screen than any smartphone, which makes it better for references and for gaming.

To learn more than you would ever need to know about PDAs of all types, check out The friendly, funny, helpful and knowledgeable folks there can answer even the most obscure questions.

Friday, May 23, 2008

I wanna be sedated.....

This past weekend I went to a sedation workshop put on by Specialty Health Education. I thought it was very good and well worth the time and expense. I've been providing sedation for a few months now without any formal training; I had a good orientation with a preceptor, but no specific training in sedation other than what I read on my own. I highly recommend "Moderate Sedation/Analgesia" by Michael Kost, who is one of the presenters for Specialty Health Education (note: I am not affiliated with them in any way, just a happy customer).

The presenter who taught my seminar gave us quotes and situations which other students had brought to previous seminars. The scariest quote was, referring to RN-administered Propofol (I'm paraphrasing), "I don't worry about giving Propofol, because we have Romazicon right in the room in case I need to reverse it." YIKES! I would hope that anyone administering sedation would know that Romazicon reverses Versed and other benzodiazepines, NOT Propofol! There is no reversal for Propofol. 

I'm doing a home-study CEU packet through this company, which I bought at the seminar. I figure that the more I know about sedation, the pharmacology of the drugs involved, and the risks to my patients, the safer we all will be.

Thursday, May 22, 2008

Warning: novice blogger at work

A basic introduction: I've been an RN for five years, and transferred from med-surg to the endoscopy room in January. The small community hospital where I work had never had a dedicated endo nurse before me; previously, the OR circulators rotated through the endo room, and they still do when I'm not working. I work with a scrub nurse (almost always the same LPN, who is a joy to work with) and four general surgeons. Colonoscopies and EGDs are our bread and butter; because we are a small hospital, we don't do ERCPs or other more extensive procedures. Once in a while we do a small ortho procedure.

I handle the sedation, monitoring, and specimens. Versed and Demerol have been the drugs of choice, but one of the docs just switched to Fentanyl. Hopefully the others will also make the switch. The anesthesia providers will provide MAC with Propofol if necessary. 

Endoscopy hasn't gotten boring for me yet. I was worried that doing the same type of procedures every day would get dull, but every case is different. Also, it is "my" room, and I have been able to set it up how I want and am working on changing the conscious sedation flowsheet. It feels good to have ownership of an area of the hospital, even if it is just one room, and being in charge of the room gives me challenges that will (hopefully!) keep me from getting bored.